Optimal Transport Destination for Ischemic Stroke Patients With Unknown Vessel Status
- 1 August 2017
- journal article
- research article
- Published by Ovid Technologies (Wolters Kluwer Health) in Stroke
- Vol. 48 (8), 2184-2191
- https://doi.org/10.1161/strokeaha.117.017281
Abstract
Background and Purpose— Patients with acute ischemic stroke (AIS) and large vessel occlusion may benefit from direct transportation to an endovascular capable comprehensive stroke center (mothership approach) as opposed to direct transportation to the nearest stroke unit without endovascular therapy (drip and ship approach). The optimal transport strategy for patients with AIS and unknown vessel status is uncertain. The rapid arterial occlusion evaluation scale (RACE, scores ranging from 0 to 9, with higher scores indicating higher stroke severity) correlates with the National Institutes of Health Stroke Scale and was developed to identify patients with large vessel occlusion in a prehospital setting. We evaluate how the RACE scale can help to inform prehospital triage decisions for AIS patients. Methods— In a model-based approach, we estimate probabilities of good outcome (modified Rankin Scale score of ≤2 at 3 months) as a function of severity of stroke symptoms and transport times for the mothership approach and the drip and ship approach. We use these probabilities to obtain optimal RACE cutoff scores for different transfer time settings and combinations of treatment options (time-based eligibility for secondary transfer under the drip and ship approach, time-based eligibility for thrombolysis at the comprehensive stroke center under the mothership approach). Results— In our model, patients with AIS are more likely to benefit from direct transportation to the comprehensive stroke center if they have more severe strokes. Values of the optimal RACE cutoff scores range from 0 (mothership for all patients) to >9 (drip and ship for all patients). Shorter transfer times and longer door-to-needle and needle-to-transfer (door out) times are associated with lower optimal RACE cutoff scores. Conclusions— Use of RACE cutoff scores that take into account transport times to triage AIS patients to the nearest appropriate hospital may lead to improved outcomes. Further studies should examine the feasibility of translation into clinical practice.This publication has 27 references indexed in Scilit:
- Early Reperfusion Rates with IV tPA Are Determined by CTA Clot CharacteristicsAmerican Journal of Neuroradiology, 2014
- Effect of the Use of Ambulance-Based Thrombolysis on Time to Thrombolysis in Acute Ischemic StrokeJAMA, 2014
- Design and Validation of a Prehospital Stroke Scale to Predict Large Arterial OcclusionStroke, 2014
- Guidelines for the Early Management of Patients With Acute Ischemic StrokeStroke, 2013
- Prehospital delay in acute stroke and TIAEmergency Medicine Journal, 2012
- Diagnosis and treatment of patients with stroke in a mobile stroke unit versus in hospital: a randomised controlled trialThe Lancet Neurology, 2012
- Factors influencing in-hospital mortality and morbidity in patients treated on a stroke unitNeurology, 2011
- A Brief Prehospital Stroke Severity Scale Identifies Ischemic Stroke Patients Harboring Persisting Large Arterial OcclusionsStroke, 2008
- Factors influencing delay in presentation for acute stroke in an emergency department in Milan, ItalyEmergency Medicine Journal, 2008
- Age and National Institutes of Health Stroke Scale Score Within 6 Hours After Onset Are Accurate Predictors of Outcome After Cerebral IschemiaStroke, 2004